Articles on shoulder health I wrote:
Next time you’re at the gym I want you to take a moment to observe during your rest periods. Make a mental note, the number of people performing chest and shoulder movements in comparison to those performing rowing movements. Next, watch how many of those swing their arm around or grasp at their shoulder after performing a chest or shoulder movement. I’m sure more than a few people reading this right now feel a burning sensation where their front deltoid and upper pectoral meet, or at the rear of the shoulder after performing pushing movements.
The numbers are staggering: it’s been estimated that nearly 40% of weight lifting injuries are to the shoulder joint, and 30% of those injuries are severe enough to restrict training or cause individuals to seek medical attention. Traditional weight training and bodybuilding routines create muscular imbalances and predispose the shoulder to injury by placing the joint in biomechanical unfavorable positions, such as externally rotating the upper arm at the bottom of the ROM. Furthermore, programs biased toward specific bodyparts generally place emphasis on developing the large primary movers while neglecting the smaller stabilization muscles required for mobility, balance, and unimpaired shoulder function.
In a nut shell, here is what occurs via a traditional bodybuilding program: The delts, internal rotators (pecs and lats), and upper trap fibers are significantly strengthened. However, the strength of the external rotators, lower trap fibers, and scapula retractors (rhomboids, rear delts, and mid trap fibers) are not strengthened. A significant strength and postural imbalance thus ensues.
So what’s actually occurring? During pressing movements the scapula stabilizers fatigue prematurely and the shoulder blades elevate and protract (come forward). This deviation from correct posture forces the rotator cuff muscles to work harder to stabilize the head of the humorous (upper arm) in the shoulder socket. The rotator cuff muscles prematurely fatigue, the head of the humorous elevates in the shoulder socket and impinges (pinches) tendons, ligaments and nerves against the acromium (that bones process at the top of your shoulder).
Now keep in mind, the shoulder itself is an inherently inflexible joint not designed to bear large loads. Thus, it’s no wonder that strength and postural imbalances combined with overuse result in impingement, rotator cuff strains and tendonitis, subacromial bursitis, and multi-directional instability.
Next week I’ll discuss exercises to avoid, ways to modify potentially harmful movements, stretches to increase capsule flexibility, and exercises to strengthen the external rotators, scapular stabilizers and lower trap fibers. Remember, you cannot build a big upper body with your arm in a sling.
Big Red
Last week we began discussing the effects of popular bodybuilding and weight training programs on shoulder health. We noted the major emphasis put into the front (chest, arms, delts) of the body in comparison to the back (traps, rhomboids). We concluded that typical split training programs result in muscular strength imbalances between the overdeveloped primary movers (pecs, delts, lats) in comparison to the underdeveloped and often atrophied stabilization muscles (scapular retractors, external rotators). We also noted a prominent postural deviation manifest in this imbalance – protracted shoulders and internal humerus rotation. Finally, we discussed the most common shoulder pathologies (impingement, rotator cuff strains and tendonitis, subacromial bursitis, and multi-directional instability) experienced.
This week, we’ll discuss ways to improve balance and stability at the shoulder joint. We’ll look at this from the perspective of pre-habilitation - decreasing the likelihood injuries may occur - rather than rehabilitation. We’ll also assume that there are no serious postural deviances at the shoulder joint – such deviances are outside the scope of this article and will be addressed separately.
There are two major issues to address: the first a flexibility imbalance examining the effects of typical weight training programs on the anterior versus posterior capsule; the second, a strength imbalance, specifically weakness in the external rotators and scapular adductors.
Glenohumeral Capsule Flexibility Imbalances
The shoulder joint is comprised of the head of the humerus (upper arm) and glenoid cavity of the scapula. The capsule is a thin bag of connective tissue that envelopes the joint. Supporting the capsule and adding stability are a series of ligaments. For the sake of this article, the ligamentous-capsular restraints will be divided into two anatomical parts: the anterior (front) and the posterior (rear).
Exercises that involve shoulder abduction and external rotation in combination with scapula protraction and elevation stretch the anterior capsule. Such exercises include presses with the elbows flared out and shoulder blades protracted, pull downs or pull ups behind the neck, and all variations of chest flies. The common pectoral stretch with the arm out straight and externally rotated also stretches the anterior capsule without fully stretching the pectoral muscles.
As hyperlaxity (excessive flexibility) is developing in the anterior capsule, a lack of flexibility is developing in the posterior capsule. Thus, a major flexibility imbalance: excessive external rotation flexibility and insufficient internal rotation flexibility. As a result, the rotator cuff muscles must work harder to hold the head of the humerus down in socket and fatigue earlier; fatigue then leads to humeral head retroversion; and shoulder pathologies ensue.
First, use correct technique when performing chest pressing exercises. Bench presses should use a grip of 1.5x that the width of the shoulders and excessive shoulder abduction should be avoided. Keep the scapula retracted and do not allow the shoulder to abduct beyond 60 degrees. To picture the shoulder positioning, imagine performing a lateral raise with a pair of dumbbells. Slowly raise your arms to your sides until a 60 degree angle has been created between your arms and the side of your body. When performing chest presses, do not let your elbows flare out beyond this point, and keep the shoulder blades squeezed together.
Second, over head presses should never be performed behind the neck and the elbows should be positioned 45 degrees anterior at the bottom of the ROM. Perform a front raise until your arms are chest height. Now slowly move your arms out to the sides until they create a 30 degree angle with the front of your body. Do not let your elbows flare out beyond this point at the bottom of the ROM during an over head press.
Next, avoid exercises that place the shoulder in compromising positions such as upright rows, front and lateral raises that exceed shoulder height, and pec deck type machines.
The stretches:
Replace the outstretched arm pectoral stretch with this:
Next, perform this stretch to improve flexibility in posterior capsule:
As discussed earlier, bodybuilders commonly develop strength imbalances between the primary shoulder movers in comparison to the shoulder stabilizers. Below is a schematic representation of how the translocator forces of the rotator cuff act to keep the head of the humerus in socket when the arm is raised.
If the rotator cuff muscles fatigue early or are cannot match the strength of the deltoid, the head of the humerus will elevate in the shoulder socket, rub against the acromium and impingement of tendons, nerves, and bursa will occur. Constant impingement results in microtrauma, tears and tendonitis. Below is a picture of impingement.
The pecs (major and minor), serratus anterior, and anterior deltoids all function to protract the scapula. As exercises for the pecs and anterior deltoids often outnumber those for the middle/lower trapezius and rhomboids, muscular imbalances between the scapula protractors and retractors occur. As a result, many amateur bodybuilders have rounded shoulders (picture of protracted scapula below)
Furthermore, the pecs, lats, and anterior/medial delts all internally rotate the humerus. How many people do you see training their external rotators? Exactly. Excessive internal humeral rotation (where your hands are no longer parallel to your sides, but rather your palm face behind you) cause several problems. First, the incidence of shoulder injuries are increased since an internally rotated humerus decreases rotator cuff muscle recruitment during pressing movements. Second, internally rotated humerus will negatively affect pec and lat hypertrophy, due to intrinsic nervous system regulation. Finally, excessive internal humerus rotation and scapula protraction often go hand in hand. Below is a picture of the often neglected external rotator muscles.
Balanced Splits
First, design your training program to promote muscular balance, not muscular imbalance. Add up your total sets for chest and anterior delts. This sum should be matched by an equal amount of sets of rowing movements (barbell, seated, pulley) and rear deltoid movements (bent over shoulder raises, rear delt machine, rear delt band pulls). Next, your total sets of over head presses should be equal to your total sets of low pulling movements (pull downs, pull ups, chin ups, etc.).
Train your Scapula Depressors
Often there is a major imbalance in strength between the upper traps and levator scapula in comparison to the lower trap fibers. As a result, the scapula easily elevates during pressing movements and the power output of the rotator cuff muscles is compromised. Use the following exercise to train the lower trap fibers. Begin the exercise at the bottom of the ROM shown on the right. Then, keeping the arms straight, depress the scapula (the reverse of the shrug) and end as the picture on the left. Begin with bodyweight 2-3 times a week and progress in weight.
Train your Scapula Retractors
The rhomboids and middle trap fibers retract the shoulder blades. A weakness in this movement is often apparent in pressing exercises where the scapula protracts and the load is shifted from the pecs to the anterior delts. This can often be seen in overdeveloped front delts.
As mentioned earlier, balance your chest and anterior delt movements with an equal amount of rowing movements and rear delt movements. Here is the key: Keep your shoulder blades depressed and concentrate on a full retraction of the scapula. Second, use only a pronated (over hand) grip. Doing so will increase the involvement of the external rotators.
Train your External Rotators
Finally, it is necessary to strengthen the external rotators. The exercise is not fancy; however a simple modification to the external rotation movement must be made. When the movement is done with the arm against the side of the body blood flow is compromised, the deltoid may be used to compensate, and the subacromial space is decreased which can lead to impingement. To increase blood flow, inactivate the deltoid, and avoid any possible impingement, place a towel roll or 3” foam cylander between the upper arm and the side. Squeeze down upon it as your perform the exercise. Make sure to keep your shoulders back and rotate the arm in controlled motion. Below is a picture demonstration:
So, to recap:
First, design your training program with balance in mind. This will not only ensure a decreased risk of injury, but will lend to a more aesthetic look (forward shoulders, over developed front delts and fake lat syndrome are only cool on the Jersey Shore).
Second, avoid exercises that increase hyperlaxity of the anterior capsule. This means no over presses or pull downs behind the neck, minimal chest flies, and no upright rows. Next, keep your shoulder blades retracted and do not let your elbows flair out to the sides. Next, perform the modified version of the pec stretch and make sure to stretch to posterior capsule in order to increase internal flexibility.
Third, do not neglect your shoulder stabilizers. Train your lower trap fibers with as much vigor and volume (and perhaps with high frequency) as your upper trap fibers. Next, train your scapula retractors with a pronated (over hand) grip. Finally, train your external rotators.
Healthy Shoulders and Happy New Year.
Big Red
Further reading:
Durral, C., Manske, R., & Davies, G. Avoiding shoulder injury from resistance training. Strength and Conditioning Journal, 23:5, 10-18. 2001.
Kolber, J., Beekhuizen, S., Cheng, S., Hellman, MA. Shoulder Joint and Muscle Characteristics in the Recreational Weight Training Population. The Journal of Strength & Conditioning Research, 23(1):148-157, January 2009.
Kolber, MJ., Beekhuizen, KS., Santore, T., Fiers, H. Implications for Specific Shoulder Positioning During External Rotator Strengthening. Strength & Conditioning Journal. 30(4):12-16, August 2008.
Tyson, A. The importance of the posterior capsule of the shoulder in overhead athletes. Strength and Conditioning Journal 27(4), 60-62. 2005.
